Healthcare Provider Details

I. General information

NPI: 1053551531
Provider Name (Legal Business Name): KRYSTAL MAE TIPPING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTAL MAE HANSEN

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S 1500 W
OGDEN UT
84404
US

IV. Provider business mailing address

200 S 1500 W
OGDEN UT
84404-4762
US

V. Phone/Fax

Practice location:
  • Phone: 801-710-1161
  • Fax:
Mailing address:
  • Phone: 801-710-1161
  • Fax: 801-944-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number491376-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: